RN Medical Reviewer, FEP

Healthy Careers Start Here The RN Medical Reviewer, FEP is responsible for thorough clinical review of the Federal Employee Program pre-service requests and post-service claim review for medical and medical drug services. The RN Medical Reviewer, FEP is responsible for determining if the requested service is covered and medically necessary using established Service Benefit Plan and medical policy criteria and by requesting the necessary clinical documentation to make a determination. Once a determination is made, the RN Medical Reviewer, FEP must clearly document the clinical decision and rationale to provide instruction for claim adjudication. The RN Medical Reviewer, FEP is relied upon to identify member and provider utilization trends as well as identify members who may be eligible for Care Management intervention. Job-Specific Requirements Bachelor’s degree in Nursing and RN licensure that is unrestricted in the state of Mississippi. Master’s degree in Nursing preferred. Minimum 2 years of clinical experience. Must possess excellent analytical and decision making skills to review and interpret complex claims and medical information to ensure claims are processed according to Service Benefit Plan provisions and Medical Policy. Must be able to work with a high degree of accuracy and attention to detail to ensure work products are of high quality. Must be able to work a flexible schedule when required. Must have above average PC skills and intermediate knowledge of Microsoft Office. Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers. At Blue Cross & Blue Shield of Mississippi, we work daily to help Mississippians find their personal answers to this question through health and wellness partnerships with quality healthcare providers, employer groups and community leaders across the state. Our goal is to help each person along their journey to a healthier life… their Blue Wellness Journey. Our health and wellness benefits are designed to support our members in understanding their health and in receiving the care they need at the right time and place, beginning with establishing a healthy relationship with a Primary Care Network Provider through an annual wellness visit at no out-of-pocket cost. We partner with our Network Providers to ensure the highest quality, evidence-based care is provided in each care setting from primary care to specialty care through our Primary Care Home, Blue Distinction+ Centers of Excellence and Maternity Care Quality initiatives. We partner with employer groups to make every workplace a healthy workplace by providing tools and information to help employees take ownership of their health and understand and make the most of their benefits, all while working to manage health and healthcare costs. We partner with community leaders and organizations to make healthy living resources available to all Mississippians through the work of the Blue Cross & Blue Shield of Mississippi Foundation, our support of the arts and culture and our Team Blue volunteers. These partnerships and our dedicated team of employees are making a difference every day, in our communities and in the lives of each person we reach. So, what does it mean to be healthy? The answer is about you, your health, your life… and all its possibilities. Live healthy. Live Blue. #J-18808-Ljbffr Bcbsms